Bayan, Semirra L.

Abstract Objective To evaluate whether systemic hormone replacement therapy (HRT) influences recurrence outcomes in postmenopausal patients with idiopathic subglottic stenosis (iSGS). Study Design Retrospective cohort study. Setting Tertiary academic medical center. Methods Postmenopausal women (≥50 years) with iSGS who underwent laser‐wedge excision between 2002 and 2024 were included. Patients were categorized by systemic HRT exposure (oral estrogen, progesterone, combined estrogen‐progesterone, or transdermal estrogen) at or before their first surgery. Overdispersion was assessed for all Poisson models; given significant overdispersion, negative binomial regression with a log‐offset for follow‐up time was used as the primary model. Surgery‐free intervals were analyzed using linear mixed models, and time to first recurrence using Cox regression. Models were adjusted for age, body mass index (BMI), parity, oophorectomy, follow‐up length, surgery type, and serial intralesional steroid injections (SILSI) use. Results Among 125 patients, 96 had never used HRT (Never HRT) and 29 used HRT, including 19 actively using HRT at presentation (Current HRT), 5 past users, and 5 subsequent users. The HRT versus Never‐HRT recurrence rate comparison was not significant (adjusted incidence rate ratio [IRR] = 0.81, 95% CI: 0.48‐1.37, P = .422). However, Current HRT use was associated with a 53% lower adjusted recurrence rate versus Never‐HRT use (adjusted IRR = 0.47, 95% CI: 0.25, 0.89, P = .0203). Surgery‐free intervals and time to first recurrence trended longer in Current HRT users but were not statistically significant. Conclusion Current HRT use at presentation was associated with significantly fewer recurrences in postmenopausal iSGS patients. These findings may inform individualized, shared decision‐making regarding HRT use in this population. Level of Evidence 3.

ABSTRACT Objective Weight loss is frequently considered a cardinal presenting symptom for patients with Zenker diverticulum (ZD). We hypothesized that weight loss in patients with cricopharyngeal muscle dysfunction (CPMD), with or without diverticula, was associated with the length of symptoms and size of diverticulum. Methods Prospective, multicenter observational study of CPMD patients with and without diverticula reporting unintentional weight loss (+WL) or no weight loss (−WL) prior to enrollment in the Prospective Outcomes of Cricopharyngeal Hypertonicity (POuCH) database. Complications and symptom response using a patient reported outcome measure, the Eating Assessment Tool (EAT‐10), were compared. Results Of 427 patients, 101 (23.6%) were +WL. Median weight loss was 14 pounds (interquartile range [IQR] 10–25). +WL cohort had a mean age of 71.5 (standard deviation [SD] 11.5) vs. 67.9 in −WL (SD 11.6, p = 0.007). Mean preoperative EAT‐10 score was 24.7 in +WL (SD 9.7) and 14.8 in −WL (SD 8.8, p < 0.0001). Higher preoperative weight loss was associated with higher preoperative EAT‐10 ( p < 0.0001, Spearman's ρ = 0.43). Size of diverticulum was associated with WL ( p = 0.003), but weight loss was highest in both large diverticula and CP bars. Duration of symptoms was not associated with weight loss ( p = 0.30). Postoperative complications in +WL and −WL patients were similar ( p = 0.78). Conclusion Unintentional weight loss is common with ZD. Patients with worse dysphagia are more likely to have more weight loss. Weight loss does not increase with the size of the diverticulum or length of symptoms. Surgery has a similar safety profile with greater improvement in dysphagia in patients reporting weight loss. Level of Evidence 3.

Objective: Endotracheal intubation can cause laryngeal injury, with clinical presentation ranging from transient hoarseness to persistent vocal cord immobility. This study examines the incidence, clinical features, and outcomes of post-intubation laryngeal injuries following procedures traditionally considered low risk for such complications. Methods: We conducted a retrospective review of adult patients who underwent tracheal intubation for surgical procedures between May 1, 2018, and December 31, 2024, and subsequently presented with postoperative laryngeal injury–related symptoms. Patients who underwent cardiothoracic, thyroid, parathyroid, or anterior cervical spine procedures were excluded. We reviewed patient demographics, airway and intubation characteristics, treatments, and clinical outcomes. Results: Among 267 824 patients undergoing 454 924 general anesthetics, 30 developed postoperative laryngeal injury (6.6/100 000; 95% CI 4.5–9.4) which did not resolve spontaneously and required laryngology evaluation. Of these 22 (67%) had well defined movement abnormalities : unilateral (n = 15) and bilateral vocal cord immobility (n = 1), unilateral hypomobility (n = 4), bilateral hypomobility (n = 1), combined unilateral vocal cord immobility with contralateral hypomobility (n = 1), and 11 (33%) had no movement abnormality . Twenty-one (64%) were intubated via video laryngoscopy. Follow-up was available for 21 patients (70%) with a median [IQR] duration of 12 [9-35] months; 15 (72%) showed partial improvement without complete resolution, while 6 showed no improvement. Conclusion: Laryngeal injury following general anesthesia with tracheal intubation is a uncommon complication. In our series, approximately two-thirds of patients had identifiable injuries, while one-third exhibited no structural abnormality. While 75% of patients demonstrated partial symptomatic improvement, however, complete resolution was not observed in any of the patients who received follow-up in our institution, underscoring the severity of this complication.

Importance Adverse events in otolaryngology–head and neck surgery (OHNS) are inconsistently reported. The Clavien-Dindo Classification has been modified and validated in several surgical subspecialties but has yet to be validated in OHNS. Objective To create and validate a modified Clavien-Dindo Classification for OHNS that reflects the severity and duration of harm for complications experienced by patients undergoing OHNS. Design, Setting, and Participants This is a multicenter survey study of subject matter experts (SMEs) from OHNS subspecialties from academic institutions within the US. A literature review identified publications reporting surgical complications in OHNS in the English language between January 2019 and April 2020. Complications were summarized and used to inform a modified Clavien-Dindo Classification. Feedback from internal SMEs was incorporated. Thirty-five clinical vignettes were created, and an electronic survey was sent to SMEs at outside institutions. Each SME was randomly assigned to 1 of 4 groups to evaluate 8 to 9 vignettes. The survey was conducted in September 2023, and data were analyzed from February to May 2024. Exposure Participation in the electronic survey. Main Outcomes and Measures Vignette scores were assessed and the Comprehensive Complication Index (CCI) calculator was used to assess cumulative morbidity. The scale is based on the grading by the Clavien-Dindo Classification and reflects overall morbidity on a scale from 0 (no complication) to 100 (death). Variability of the CCIs between reviewers, the primary outcome, was summarized with the SD. The percentage of reviewers with a high (≥26.2) or low (&amp;lt;26.2) CCI within a vignette was reported. Reliability was summarized using Krippendorff α. Results Of 106 SMEs, 43 (response rate, 40.6%) completed at least 1 vignette. Eighteen of 35 vignettes (51.4%; 95% CI, 34.9%-68.0%) had unanimous high CCI, and 8 of 35 vignettes (22.9%; 95% CI, 8.9%-36.8%) had unanimous low CCI (overall categorical agreement, 74.3%; 95% CI, 59.8%-88.8%). On average, the Krippendorff α was 0.74, indicating moderate reliability. A total of 21 850 OHNS complications were reviewed and categorized as surgical or medical with 12 including subcategorization for specificity. Each category was then assigned a modified OHNS Clavien Dindo classification grade. Conclusions and Relevance In this survey study of OHNS experts, a modified OHNS Clavien-Dindo Classification was developed and validated using case vignettes. The modified Clavien-Dindo Classification provided a granular subcategorization for each complication category and grade, duration of harm, and an overall summary complication score (CCI). Results suggest the modified OHNS Clavien-Dindo Classification reliably differentiated between high-grade and low-grade OHNS complications and could be utilized for assessing surgical outcomes.

BACKGROUND Glossopharyngeal neuralgia (GPN) is a rare disorder characterized by severe, episodic pain along the sensory distribution of cranial nerve (CN) IX. Bilateral GPN presents unique challenges for consideration of microsurgical treatment due to potential risks of postoperative dysphagia and cardiac arrhythmias associated with resection of bilateral CN IX/X. Here, the authors describe successful staged bilateral microsurgical rhizotomy of CN IX and upper CN X rootlets to treat bilateral GPN. OBSERVATIONS A 54-year-old female presented with right GPN and underwent a right retrosigmoid craniotomy with rhizotomy, resulting in complete resolution of pain. During the following year, the patient developed left GPN and was considered for the same surgical intervention. However, prior to pursuing surgical intervention, evaluation of her swallowing function was conducted to stratify her risk of pharyngeal sensory denervation or dysphagia, and to confirm her suitability for left-sided rhizotomy. Given the patient’s normal oropharyngeal swallowing function on videofluoroscopic swallow study, she underwent left retrosigmoid craniotomy with rhizotomy. At the 3-month follow-up, the patient described complete resolution of pain and normal swallowing function. LESSONS With the use of comprehensive patient evaluation between surgical stages, staged bilateral microsurgical rhizotomy is a feasible and safe treatment option for carefully selected patients with bilateral GPN. https://thejns.org/doi/10.3171/CASE25359

Objective: To develop, implement, and evaluate a novel process used for residency application review that deemphasizes metrics known to create bias with the goal of interviewing and matching a more diverse resident cohort. Methods: Between 2020 and 2023, a novel standardized rubric and application review process were developed and implemented at the authors’ academic training program. The rubric deemphasized USMLE scores, honor society membership, and number of publications while utilizing an AI-driven pre-sort of applications, facilitating holistic review. This weighted applicant attributes identified in personal statements, life experiences, achievements in community, leadership roles, otolaryngology-specific impressions highlighted in letters of recommendation, and otolaryngology-specific research and publications similarly to academic metrics (clerkship grades and standardized test scores). Demographics of applicants interviewed and matched into our program were compared pre- and post-implementation using descriptive statistics. Results: Using a standardized rubric to review residency applications that deemphasizes traditional metrics, the authors’ otolaryngology residency program has interviewed, ranked, and matched more diverse candidates. As a result, from 2019 to 2022, the overall resident cohort has diversified from 4% historically marginalized residents to 24%, from 28% female residents to 44%, and from 33% of residents outside our geographic region to 66%. Conclusion: There is significant underrepresentation among otolaryngology residents. Selection based upon USMLE Step 1 scores, honor society membership, and number of publications have been shown to restrict diversity. Purposeful holistic review increases diversity in interviewed and matched resident cohort.

ABSTRACT Background Idiopathic subglottic stenosis (iSGS) occasionally affects women of childbearing age. Surgical intervention is the primary treatment, yet limited research exists on factors influencing disease severity. This study explores the impact of hormonal contraception on iSGS recurrence rates and surgery‐free intervals. Methods This retrospective study was conducted at a tertiary academic care center. Patients using hormonal birth control (e.g., estrogen‐progesterone pills, progesterone implants) during their first procedure were classified in “Birth Control (BC)” group, while those not using contraceptives were placed in “No Birth Control (NBC)” group. Poisson regression evaluated recurrence rates, and Mann–Whitney tests assessed surgery‐free intervals. Kaplan–Meier analysis estimated time to first recurrence, adjusting for age and follow‐up duration. Results Twenty‐six patients were in the NBC group and 12 in the BC group (average ages 37 and 34, respectively). Patients in the NBC group were 2.6 times more likely to experience recurrence compared to those in the BC group ( p = 0.001). The expected number of recurrences for the BC group was 0.4 times that of the NBC group (95% CI: 0.2–0.7; p = 0.001). Furthermore, patients taking birth control were significantly less likely to have a first recurrence (HR: 0.4; 95% CI: 0.2–0.9; p = 0.025) and had longer times to first recurrence (Figure 1; p = 0.031). Conclusions Birth control appears to protect against iSGS severity, potentially through hormonal mechanisms. Hormonal contraception may serve as a non‐surgical alternative for managing iSGS. Future prospective studies may evaluate outcomes in newly diagnosed iSGS patients started on birth control compared to those not using hormonal contraceptives. Level of Evidence 3.

ABSTRACT Background Managing idiopathic subglottic stenosis (iSGS) during pregnancy presents distinct clinical challenges. As pregnancy is a naturally dyspneic state, the development of iSGS may exacerbate respiratory symptoms and compromise the airway—potentially impacting pregnancy and delivery decisions. This study characterizes surgical management strategies and outcomes in pregnant patients with symptomatic iSGS. Methods We conducted the largest known multi‐institutional retrospective review of pregnant patients who underwent endoscopic intervention for iSGS. Demographics, procedural details, anesthesia and medication use, and maternal and neonatal outcomes were analyzed. Results Twelve patients underwent 15 endoscopic procedures during pregnancy: 9 laser wedge excisions (8 CO 2 laser and 1 coblator) and 6 balloon dilations. Three additional procedures in different patients occurred postpartum (2–11 months after delivery). Higher‐risk pregnancies included two twin gestations, one patient with multiple surgeries during two different pregnancies, and two patients over age 35. Most interventions (87%) occurred in the second trimester. Fetal monitoring was performed preoperatively and postoperatively. Fentanyl and propofol were used in 88% and 94% of cases, respectively; rocuronium was the most common neuromuscular blocker (70%). One patient underwent balloon dilation via flexible bronchoscopy without anesthesia. Jet ventilation was used in 53% of cases, and Size C Kleinsasser laryngoscopes in 47%. Median procedure times were 75, 19, and 18 min for laser wedge excision, balloon dilation, and coblation, respectively. Most patients delivered full‐term with no surgical or postpartum complications. Conclusions Endoscopic intervention for iSGS during pregnancy appears safe and effective, even in high‐risk cases. These findings support individualized airway management and inform future practice. Level of Evidence 4.

Introduction: Despite ongoing diversity initiatives, Otolaryngology – Head and Neck surgery continues to face a widening representation gap as the Latinx population in the United States grows. To address this disparity, novel strategies for recruiting Latinx medical students into the specialty must be explored. Methods: A descriptive, cross-sectional survey was distributed to Latinx medical students in the United States via social media platforms (Facebook, Twitter, Instagram) and Latino Medical Student Association (LMSA) chapters. Results: Most respondents were unfamiliar with Otolaryngology-specific health disparities affecting Latinx communities and indicated an interest in learning more about these disparities. Most respondents indicated that early exposure to Otolaryngology disparities affecting Latinx communities could increase interest in exploring the specialty. Additionally, most participants deemed a department's commitment to diversity, equity and inclusion and opportunities to serve Latinx patients to be necessary residency program attributes when deciding between programs (69.2% and 66.7%, respectively). Conclusion: Integrating community outreach and education on Otolaryngology-related health disparities into undergraduate medical education may serve as a promising strategy to enhance Latinx recruitment and representation in the specialty.

ABSTRACTObjectiveThere is currently not a marker of disease severity in idiopathic subglottic stenosis (iSGS). Our objective was to characterize iSGS patients' disease severity using endoscopic surgery rates.MethodsThis was a two‐center retrospective analysis of iSGS patients with a minimum of 4 years of follow up following an initial endoscopic procedure (laser wedge excision (LWE) or endoscopic dilation (ED)). Disease severity was classified into Groups A–C, based on whether patients had fewer (Group A), the same number (Group B), or more surgeries (Group C) in years 3–5 compared to years 1 and 2. Disease severity proportions were compared across institutions using chi‐square analysis. Nonparametric testing compared clinical characteristics such as age, BMI, and GERD across severity groups.ResultsThere were 104 patients from institution 1 and 53 patients from institution 2 that were all female and predominantly Caucasian. Both institutions had clinically and statistically similar proportions of patients in Group A (64% vs. 62%), Group B (20% vs. 19%), and Group C (16% vs. 19%) disease (p > 0.05). No clinical characteristic (e.g., age, sex, race, BMI, GERD) was associated with disease severity.ConclusionAcross tertiary care institutions there is a consistent proportion of iSGS patients who either demonstrate nonrecurrent/decelerating (Group A), stable but persistent (Group B), or rapidly recurring disease (Group C). Two‐year surgery rates appear to be an important timepoint for providing expectations to patients on the likelihood of possessing severe disease.Level of Evidence4